Provider Demographics
NPI:1700385853
Name:DIXON, RADUSTA
Entity Type:Individual
Prefix:MS
First Name:RADUSTA
Middle Name:
Last Name:DIXON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2016 CRAFT ST
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41101-2527
Mailing Address - Country:US
Mailing Address - Phone:740-352-5617
Mailing Address - Fax:
Practice Address - Street 1:303 GERVAIS RD
Practice Address - Street 2:
Practice Address - City:FRANKLIN FURNACE
Practice Address - State:OH
Practice Address - Zip Code:45629-8742
Practice Address - Country:US
Practice Address - Phone:740-259-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-05
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.16210171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCDCA.162120OtherCHEMICAL DEPENDENCY PROFESSIONALS BOARD